Why "Evidence-Based" Therapy is a Straw Man

Misconceptions About Modern Therapeutic Practices

Modern therapeutic practices often face scrutiny and misunderstanding, particularly when it comes to therapy methods and the concept of evidence-based therapy. Many people mistakenly believe that evidence-based therapy is a one-size-fits-all approach, disregarding the nuanced and individualized nature of mental health treatment. This misconception can lead to the erroneous belief that therapies not labeled as "evidence-based" are ineffective or inferior. In reality, the term "evidence-based" is frequently used as a marketing tool rather than a definitive measure of a therapy's efficacy. This oversimplification ignores the complexity of human psychology and the diverse needs of individuals seeking mental health support.

Through large scale studies over decades, it has been observed by researchers that despite the explosion of new methods and diagnostic procedures in therapy, the overall efficacy of psychotherapeutic treatment has not significantly improved (1). In fact, of all factors that impact therapy outcomes, treatment model, technique, or method makes the "smallest percentage size contribution to outcome of any known ingredient," (2). In other words, large scale research suggests that different treatment approaches do not definitively produce better outcomes than others. However, according to Scott D. Miller “Study after study, and studies of studies show that the average client is better off than 80% of untreated sample,” (2).

Limitations of Therapy Labels: A Critical Look at Evidence-Based Practice

The labels used in therapy, particularly "evidence-based practice," often come with significant limitations that can obscure the true efficacy of various therapeutic approaches. While the term "evidence-based practice" suggests a rigorous, scientific foundation, it can also create a misleading hierarchy among therapies. This label may cause individuals to overlook valuable treatments that do not fit neatly into this category but are nonetheless effective for certain conditions or populations. Additionally, the focus on evidence-based therapy can sometimes prioritize short-term outcomes over long-term well-being, neglecting the importance of sustained mental health improvement.

Moreover, the criteria for what constitutes "evidence" can be narrow, often excluding qualitative data and patient experiences that are crucial for understanding the full impact of a therapy. This can result in a skewed perception of what is effective, potentially marginalizing innovative or holistic approaches that do not conform to traditional research methodologies. It is essential to recognize that the therapeutic process is inherently complex and multifaceted, requiring a broader perspective that values both empirical evidence and individual experiences. By critically examining these labels, mental health professionals and patients alike can make more informed decisions that better address the diverse needs of those seeking support.

The Role of Research in Effective Therapy

Research plays a crucial role in developing effective treatments and advancing the field of psychotherapy. It provides a scientific basis for understanding which methods are most beneficial for specific conditions, helping clinicians make informed decisions. However, it is important to recognize that research alone cannot capture the full complexity of human experience and the therapeutic process. While empirical studies offer valuable insights, they often rely on controlled environments that may not reflect real-world scenarios.

Moreover, research can sometimes be influenced by funding sources or publication biases, which may skew the perceived efficacy of certain treatments. This underscores the need for a balanced approach that integrates research findings with clinical expertise and patient preferences. By combining these elements, therapists can tailor their interventions to meet the unique needs of each individual, leading to more personalized and effective care.

Additionally, ongoing research is essential for continually improving therapeutic practices and adapting to new challenges in mental health. It encourages innovation and the development of new techniques that can address emerging issues. Ultimately, the role of research in effective treatment is to provide a foundation of knowledge while remaining flexible and responsive to the evolving landscape of mental health care.

Why Context Matters in Therapeutic Outcomes

Context plays a pivotal role in determining the outcomes of therapeutic interventions. The effectiveness of therapy is not solely dependent on the techniques used but also on the environment in which it is delivered and the unique circumstances of each patient. Factors such as cultural background, socioeconomic status, and personal history can significantly influence how a patient responds to treatment. Ignoring these contextual elements can lead to suboptimal outcomes and a lack of engagement from the patient.

Furthermore, the therapeutic relationship itself is a critical component of successful treatment. Trust, empathy, and mutual understanding between the therapist and patient can greatly enhance the effectiveness of any therapeutic approach. Research has shown that the quality of the therapeutic alliance is often a stronger predictor of positive outcomes than the specific type of therapy used. This highlights the importance of creating a supportive and individualized therapeutic environment.

Additionally, external factors such as family dynamics, social support, and life stressors can impact the progress and sustainability of therapeutic gains. Therapists must consider these elements when designing and implementing treatment plans to ensure they are addressing the whole person, not just the symptoms. By acknowledging and integrating context into therapeutic practice, mental health professionals can provide more comprehensive and effective care, ultimately leading to better long-term outcomes for their patients.

Moving Beyond Simplistic Therapy Debates

The ongoing debates about the superiority of different therapeutic approaches often oversimplify the complexities of mental health treatment. These discussions frequently pit one method against another, creating a false dichotomy that overlooks the multifaceted nature of effective therapy. It is essential to move beyond these simplistic debates and recognize that no single approach holds the key to addressing all mental health issues.

Each therapeutic method has its strengths and limitations, and the effectiveness of any given approach can vary widely depending on the individual and their specific circumstances. For instance, cognitive-behavioral therapy (CBT) may be highly effective for some individuals dealing with anxiety, while others may benefit more from psychodynamic therapy or mindfulness-based interventions. The key is to adopt a flexible, integrative approach that draws on the best practices from various therapeutic models.

Moreover, the focus should shift from arguing about which therapy is superior to understanding how different approaches can complement each other. By fostering collaboration among mental health professionals and encouraging the integration of diverse therapeutic techniques, the field can better serve the complex needs of patients. This holistic perspective acknowledges that mental health is influenced by a myriad of factors, including biological, psychological, and social elements.

Additionally, it is crucial to involve patients in the decision-making process, respecting their preferences and values. Empowering patients to take an active role in their treatment can enhance engagement and improve outcomes. Moving beyond simplistic therapy debates allows for a more nuanced and effective approach to mental health care, ultimately benefiting both practitioners and patients.

(1) Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness. Miller, S.D., Hubble, M.A., & Chow, D. American Psychological Association. (2020).

(2). https://scottdmiller.com/wp-content/uploads/What%20Works%202010.PDF

Codependency and Therapy

What is codependency and how can therapy help with it?

In his best-selling book, John Bradshaw wrote, “Much has been written about codependency. All agree that it is about the loss of selfhood,” (1). While being trained at the former Bay Area affiliate of the John Bradshaw center one of my supervisors would quote Bradshaw as saying that codependency was the ‘disease of the lost self.’ But what does this really mean? In order to understand this, we need to know about the conditions in which codependency forms.

Codependency refers to a pattern or set of patterns wherein we disconnect from the truth or reality of our own embodied experience. Why would one do this? We do this because we have learned that something about our experience is threatening to the stability of our relationship to a significant other.

In the process of disconnecting from ourselves, we experience several trickle-down impacts. These impacts are summarized in this list from Pia Melody:

Codependents have difficulty

1. Experiencing appropriate levels of self-esteem

2. Setting functional boundaries

3. Owning and expressing their own reality

4. Taking care of their adult needs and wants

5. Experiencing and expressing their reality moderately (2)

Many definitions of codependency are vague, misleading, or simply non-existent (3). When I refer to codependency I am referring to an observable internal dynamic that takes shape in external relationships. In other words, the pattern is observable in how we relate to ourselves and how we relate to others. These dynamics are formed through the course of our emotional development, and thus in response to our primary caretakers. This is why Bradshaw goes on to say that codependency is a “disease of the developing self that does not manifest fully until one is in an adult relationship,” (1).

Many people think they had a normal childhood. However when we look deeper, they realize they experienced a lack of emotional support. As adults they now find it difficult to feel and express their true feelings. Furthermore, if they were shamed for having certain feelings, this adds to the difficulty. Now their feelings can also be experienced as threatening to their sense of security.

People-pleasing, fawning, feigning, and other protections.

Codependency is often connected with people-pleasing. Why is that? If we learn that our emotional experience can lead to a threat to our sense of security with a significant other, we need to find a way to mitigate that threat. In trauma-informed practice most people are familiar with the fight, flight, and freeze responses. More recently clinicians have begun to connect “fawning” and “feigning” as a systemic response to threat. People pleasing falls under the category of these two. Each are strategies to to avoid conflict and the potential threat it entails. Each ultimately require us to disconnect from our true needs, desires, and emotions - some may say our true selves.

While the strategies of fawning and feigning are very much a part of the codependency presentation, they are not the only defenses that can operate under this moniker. The truth is each person may rely on defenses a little differently. If we have learned to disconnect from our feelings we may also do so unconsciously through repression, denial, and dissociation. We may rationalize our true feelings away. We may minimize our hurt or anger in order to avoid conflict. All of these processes are meant to mitigate the potential for threat.

The problem with such protective strategies is that over time they erode our ability to experience genuine fulfillment and connection in our relationships. So for this reason, in my work with clients I focus on both practical skills around helping them identify and express feelings when they struggle to do so. I help them learn how their feelings are vital to their relationship to themselves and others. I help clients to connect their feelings to their relational needs, desires, and boundaries. I have seen these practical skills have a transformative effect on my clients time and time again. They help clients develop a healthy sense of self-esteem, competence in setting limits, verbalizing their needs and emotions. This often results in a lessening of internal conflict and a capacity to manage conflicts in relationship with significantly less drama and sense of threat.

At a certain point in our work, I will help the client to start to connect with their inner child. As we learn practical skills to manage our emotions, we can then begin to deepen awareness into how these patterns, or as I call them ‘templates,’ began to develop in the first place. This often brings up feelings of fear, grief, and/or anger that have been disconnected from for a long time. We develop a relationship to the embodied inner child experience so that this part of us can begin to an internalize a compassion, patient, and tolerant relationship. As this part of us begins to develop trust that we can hold it lovingly, they don’t have to rely on other ways to protect themselves which create damaging consequences which could include: low self-esteem, dissociation, dis-satisfying relationships, shame spirals, depression, and anxiety.

The good news is that it is possible to experience significant growth and healing from these patterns. Please don’t hesitate to contact me if you are interested in learning more about how I work with codependency in therapy.

(1) Bradshaw, John. Healing the Shame That Binds You (p. 34).

(2)Mellody, Pia; Wells Miller, Andrea; Miller, J. Keith. Facing Codependence: What It Is, Where It Comes from, How It Sabotages Our Lives . Kindle Edition.

(3) https://en.wikipedia.org/wiki/Codependency

Nonduality and the Psychotherapy of Transcendence

How does nonduality relate to psychotherapy? How might it be distinct? Is nonduality a method or approach to psychotherapy? What does nonduality offer psychotherapy?

In order to answer these questions we must start with how we understand who and what we are and what therapy is. In technical terms (which you can leave aside if you choose) we must try to understand the ontology behind our approach in order to understand the epistemology. That is, we must be differentiate how each approach sees itself in relationship to the process of being human or if you favor redundancy, being a human being.

Encyclopedias could be written about what psychotherapy actually is. Generally speaking, we can think of psychotherapy as an interpersonal methodology applied with the intent of helping the client develop awareness/insight and into their mental, emotional, and behavioral patterns in order to facilitate change. Some schools of therapy may frame therapy more centrally as a process of skill-building also aimed at facilitating change.

In either instance, therapy operates within a primarily secular worldview that is both individual to each therapist, and in the context of the therapeutic interaction intends to stand outside of belief (unless that is we specifically seek out a faith-based therapist) resulting in opaque or inexplicit ontology. Yet, whether or not belief is explicit it is impossible that the therapist and client would not include their respective world-views in the therapy process. Meaning, how the clients understand themselves in relationship to their world and existence must be part of the therapy process and by proxy how their therapist understands themselves in relationship to the world is impossible to eradicate from the therapy process, no matter how client-centered our values are.

Why am I making this point? Well the aim of conventional psychotherapy methods are built upon presuppositions that both client and therapist bring into the room. In the most general, structural sense some of these presuppositions are:

• the client exists as a sense-of-self

• the client is experiencing problems related to that sense-of-self

• those problems are related to one or more areas of dysfunction within the sense-of-self system

• those problems may be explained variably by different epistemological and etiological concepts (i.e. therapeutic theories and methodologies).

• emotional and relational development are emphasized as structurally formative factors in problems with the sense-of-self

• therapy seeks to ameliorate problems of the sense-of-self

These presuppositions are distinct from a nondual orientation to therapy which may respond to each point as such:

• the client sense-of-self exists as a relativity (some schools of psychotherapy may agree) and from another perspective the sense-of-self is non-existent; it is empty of self-nature

• “Problems,” or the roots of mental affliction, arise from the client’s identification with the sense-of-self as being substantial

• investment in remedying the sense-of-self reinforces the belief that the sense-of-self is ultimately existent and important

• Nonconceptual/Nondual Awareness is the ground of all experience

• the experiential revelation of Nonconceptual Awareness naturally divests energy from the identification with the sense-of-self, emphasizing experiential selfless spaciousness

• the conceptual mind may or may not naturally re-assert itself into Nonconceptual space

• The conceptual mind is divested of it’s relevance

• Resting in experiential selfless spaciousness

• Problems can not be constituted; awareness is unstructured; there is no it, there is no that, there is no I, there is no there.

The aims of conventional and nondual psychotherapy are different. Conventional therapy is a useful and important endeavor. It often implies certain presuppositions that are not explicit, however the reality is that most people who go to therapy find it helpful. In therapy we look at how we became who we are identified with today, and how certain patterns of emotion, affect, and thought serve or do not serve us— broadly speaking.

Nondual therapy is a totally transpersonal-consciousness based approach which is based on going beyond identification with the sense-of-self to an innate, experiential ground of being that has nothing to do with who we think we are. This is a psychotherapy of transcendence.

Boundaries 101

Boundaries are an often cited, yet commonly misconstrued psychological idea. Difficulty with boundaries is one of the most common issues I see with clients dealing with a variety of presenting problems—from anxiety, and depression to life transitions and relationship conflict. I had the good fortune of completing a two year training with the former Bay Area affiliate of the John Bradshaw Center where a premium was placed on learning boundaries.

Perhaps the easiest example of a boundary system is that of the cell wall. Simply put, cell walls keep out the bad stuff and let in the good stuff. While that may be an oversimplification, it is a helpful guiding principal. Similarly, our boundaries are a part of our emotional self-care system. They express a limit, whether that be physical, emotional, sexual, intellectual, or spiritual. When we have poor boundaries, we open ourselves to harmful experiences or dissatisfactory relationships. On the other hand, if we have too rigid of boundaries, we might not let in some of the emotional nourishment we need.

I teach people that boundaries are always connected to our feelings and needs. You might say that feelings are our best guides to our needs and limits. Often when people come to therapy, they have difficulty identifying their feelings. This is common, and not a reason to feel shame. However, when we have difficulty identifying our feelings, it is very hard to ask for what we need in relationship and to set limits.

The first step in having good boundaries is to develop awareness of our feeling states. How do I experience myself when I am angry? Sad? Ashamed? Scared? Hurt? Knowing the cues to these emotional experiences allow us to plug into our emotional self-care system, to clearly define our needs and limits. For example if I know I am sad, I might just need to ask for some reassurance or for someone else to listen while I express my feelings. If I’m frustrated or resentful with someone else, its very possible I have been neglecting my boundaries. If these feelings arise, there is always an opportunity to check in with myself and say… “Do I have a limit here that I haven’t expressed?” “Is there something I am needing that I haven’t asked for?”

Boundary work is a practice. It’s an ongoing learning process that takes time, self-observation, and self-love. We are all works in progress. I am confident that you can learn boundary skills and that knowing these skills will benefit you greatly. I will post more in the future about this very important topic, but for now… be well!